Physical Rehabilitation for Veterinary Technicians and Nurses

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5 Physical Rehabilitation for Veterinary Technicians and Nurses Edited by Mary Ellen Goldberg Instructor VetMedTeam, LLC Canine Rehabilitation Institute Staff Organizing Committee Academy of Physical Rehabilitation Veterinary Technicians Boynton Beach, FL, USA and Julia E. Tomlinson Twin Cities Animal Rehabiltiation & Sports Medicine Clinic, LLC Founder, American Association of Rehabilitation Veterinarians Minneapolis, MN, USA

6 This edition first published John Wiley & Sons, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at The right of Mary Ellen Goldberg and Julia E. Tomlinson to be identified as the authors of the editorial material in this work has been asserted in accordance with law. Registered Office John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA Editorial Office 111 River Street, Hoboken, NJ 07030, USA For details of our global editorial offices, customer services, and more information about Wiley products visit us at Wiley also publishes its books in a variety of electronic formats and by print on demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging in Publication Data Names: Goldberg, Mary Ellen, editor. Tomlinson, Julia E., 1972 editor. Title: Physical rehabilitation for veterinary technicians and nurses / edited by Mary Ellen Goldberg, Julia E. Tomlinson. Description: Hoboken, NJ : Wiley, Includes bibliographical references and index. Identifiers: LCCN (print) LCCN (ebook) ISBN (pdf) ISBN (epub) ISBN (pbk.) Subjects: MESH: Physical Therapy Modalities veterinary Animal Technicians Classification: LCC SF925 (ebook) LCC SF925 (print) NLM SF 925 DDC /582 dc23 LC record available at Cover design: Wiley Cover images: Courtesy of Mary Ellen Goldberg and Julia Tomlinson; (Equine image) Courtesy of Dr. Steve Adair and Dawn Phillips Set in 10/12pt Warnock by SPi Global, Pondicherry, India

7 v Contents List of Contributors vii 1 Introduction to Physical Rehabilitation for Veterinary Technicians/Nurses 1 Mary Ellen Goldberg 2 Joining a Rehabilitation Team 11 Julia E. Tomlinson 3 The Veterinary Technician and Rehabilitation Pain Management 26 Mary Ellen Goldberg 4 Communicating the Treatment Plan 49 Tracy A. Darling and Cynthia M. Otto 5 Manual Therapy Treatment 59 Judy Coates 6 Home Exercises 79 Abby Rafferty and Jacqueline R. Davidson 7 Supporting the Client and Patient 95 Robin Downing and Mary Ellen Goldberg 8 Nutritional Counseling 109 Kara M. Burns 9 Motivating Your Patient 127 Megan Nelson and Julia E. Tomlinson 10 The Disabled Patient Part 1: Assistive Devices and Technology 145 Mary Ellen Goldberg and Julia E. Tomlinson 11 The Disabled Patient Part 2: The Neurological Patient 163 Stephanie Kube and Mary Ellen Goldberg 12 The Disabled Patient Part 3: Special Considerations for Geriatrics 187 Mary Ellen Goldberg and Julia E. Tomlinson

8 vi Contents 13 The Disabled Patient Part 4: Home Nursing Care 205 Julia E. Tomlinson and Elizabeth E. Waalk 14 Modalities Part 1: Thermotherapy 218 Julia E. Tomlinson and Mary Ellen Goldberg 15 Modalities Part 2: Laser Therapy 231 Kristin Kirkby Shaw and Liz Brown 16 Modalities Part 3: Electrotherapy and Electromagnetic Therapy 241 Shari Sprague and Mary Ellen Goldberg 17 Modalities Part 4: Therapeutic Ultrasound 262 Carolina Medina and Wendy Davies 18 Modalities Part 5: Shockwave Therapy 273 Douglas Stramel and Angela Stramel 19 Therapeutic Exercises Part 1: Land Exercises 286 Janice L. Huntingford and Jessy Bale 20 Therapeutic Exercises Part 2: Hydrotherapy (Aquatic Therapy) 308 Pádraig Egan and Noel Fitzpatrick 21 Troubleshooting as a Team 329 Amie Hesbach, Julia E. Tomlinson, and Erin White 22 Equine Rehabilitation 347 Steve Adair and Dawn Phillips 23 Adjunctive Therapies Part 1: Acupuncture and Traditional Chinese Medicine 377 Carolina Medina and Mary Ellen Goldberg 24 Adjunctive Therapies Part 2: Veterinary Chiropractic 390 Robin Downing 25 Adjunctive Therapies Part 3: Myofascial Trigger Point Therapy 398 Douglas Stramel and Angela Stramel Index 407

9 vii List of Contributors Steve Adair, MS, DVM, Diplomate ACVS, ACVSMR, CERP Equine Performance and Rehabilitation Center University of Tennessee Veterinary Medical Center Knoxville, TN, USA Jessy Bale, BSc, LVT, RVT Essex Animal Hospital Essex, Ontario, Canada Liz Brown, LVT, CCRA Aratana Therapeutics, Inc. Leawood, KS, USA Kara M. Burns, MS, MEd, LVT, VTS (Nutrition) Academy of Veterinary Nutrition Technicians Wamego, KS, USA Judy Coates, M.Ed, MSPT, CCRT Coates Canine Physical Therapy Lebanon, NH, USA and Canine Rehabilitation Institute, Inc. Wellington, FL, USA Tracy A. Darling, RVT, VTS Small Animal Internal Medicine Penn Vet Working Dog Center University of Pennsylvania, School of Veterinary Medicine Philadelphia, PA, USA Jacqueline R. Davidson, DVM, MS, DACVS, DACVSMR, CVA, CVMA, CVSMT, CCRP, CERP, CCRT, CVPP Department of Small Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University College Station, TX, USA Wendy Davies, CVT, CCRA, VTS physical rehabilitation University of Florida Small Animal Hospital Gainesville, FL, USA Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CCRP, CVC The Downing Center for Animal Pain Management, LLC Windsor, CO, USA and Affiliate Faculty, Colorado State University College of Veterinary Medicine Fort Collins, CO, USA Pádraig Egan, BVM&S, CertAVP (GSAS), MRCVS Fitzpatrick Referrals, Surrey, UK Noel Fitzpatrick, DUniv, MVB, DSAS(Orth), DACVSMR Fitzpatrick Referrals, Surrey, UK

10 viii List of Contributors Mary Ellen Goldberg, BS, LVT, CVT, SRA, CCRA, CVPP, VTS lab animal, physical rehabilitation International Veterinary Academy of Pain Management Orlando, FL, USA VetMedTeam, LLC Saint Petersburg, FL, USA and Canine Rehabilitation Institute, Inc. Wellington, FL, USA Amie Hesbach, DPT, CCRP EmpowerPhysioPeT Maynard, MA, USA Janice L. Huntingford, DVM, DACVSMR, CVA, CVPP, CCRT, CAVCA Essex Animal Hospital Essex, Ontario, Canada Stephanie Kube, DVM, DACVIM, CVPP, CCRT Veterinary Neurology and Pain Management Center of New England Walpole, MA, USA Carolina Medina, DVM, DACVSMR, CVA Coral Springs Animal Hospital Coral Springs, FL, USA Megan Nelson, BS, CVT American College of Veterinary Sports Medicine and Rehabilitation Fort Collins, CO, USA Cynthia M. Otto, DVM, PhD, DACVECC DACVSMR, CCRT Penn Vet Working Dog Center University of Pennsylvania, School of Veterinary Medicine Philadelphia, PA, USA Dawn Phillips, LVT, CERP University of Tennessee College of Veterinary Medicine Knoxville, TN, USA Abby Rafferty, BS, LVT, CCRP Veterinary Medical Teaching Hospital, College of Veterinary Medicine & Biomedical Sciences Texas A&M University College Station, TX, USA Kristin Kirkby Shaw, DVM, MS, PhD, CCRT, DACVS SA, DACVSMR Animal Surgical Clinic of Seattle Shoreline, WA, USA Shari Sprague, MPT, CCRT, FP MT, CCKTP PUP Rehabilitation and Conditioning Lauderhill, FL, USA Angela Stramel, LVT, MSPT, CMTPT Advanced Care Veterinary Services Lewisville, TX, USA Douglas Stramel, DVM, CVA, CVPP Advanced Care Veterinary Services Lewisville, TX, USA Julia E. Tomlinson, BVSc, MS, PhD, DACVS, DACVSMR, CCRP, CVSMT American College of Veterinary Sports Medicine and Rehabilitation, Fort Collins, CO, USA and Twin Cities Rehabilitation & Sports Medicine Clinic, Burnsville, MN, USA Elizabeth E. Waalk, CVT Twin Cities Rehabilitation & Sports Medicine Clinic Burnsville, MN, USA Erin White, CVT, CCRA Sport Vet Canine Rehabilitation and Sports Medicine Tallahassee, FL, USA and Affiliated Veterinary Specialists Orange Park, FL, USA

11 1 1 Introduction to Physical Rehabilitation for Veterinary Technicians/Nurses Mary Ellen Goldberg 1,2,3 1 International Veterinary Academy of Pain Management, Orlando, FL, USA 2 VetMedTeam, LLC, Saint Petersburg, FL, USA 3 Canine Rehabilitation Institute, Inc., Wellington, FL, USA CHAPTER MENU What is Rehabilitation?, 1 History of Human Physical Therapy, 2 History of Veterinary Physical Rehabilitation, 2 Specifics About Veterinary Physical Rehabilitation, 3 How do Veterinary Technicians and Nurses fit in?, 4 Where Can I Become a Certified Rehabilitation Veterinary Technician?, 5 What is Involved in Becoming a CCRA, CCRP, CVMRT, CERA, or CERP?, 5 Practice Regulations for Veterinary Technicians, 6 Working in the Physical Rehabilitation Field, 6 Therapeutic Exercises, 7 Manual Techniques, 7 Physical Modalities, 7 Conditions that can Benefit from Physical Rehabilitation, 8 Conclusion, 9 References, 9 As veterinary technicians, we vow to further our knowledge and competence through a commitment to lifelong learning (NAVTA, 1987). Over the past decade, awareness of animal physical rehabilitation has increased, and rehabilitation has become a rapidly growing service within veterinary specialty hospitals, referral centers, and primary care practices. Every day, we hear about laser therapy and underwater treadmills, equipment that was not traditionally covered in the veterinary technician s college curriculum. Learning more about rehabilitation enables the veterinary technician to better assist the supervising veterinarian when physical rehabilitation therapies are recommended. This chapter aims to answer some questions about rehabilitation for veterinary technicians and nurses. What is Rehabilitation? Physical rehabilitation is the treatment of injury or illness to decrease pain and restore function (AARV, 2015). Rehabilitation is used Physical Rehabilitation for Veterinary Technicians and Nurses, First Edition. Edited by Mary Ellen Goldberg and Julia E. Tomlinson John Wiley & Sons, Inc. Published 2018 by John Wiley & Sons, Inc.

12 2 Introduction for Veterinary Technicians/Nurses to address acute injuries and chronic injuries or diseases that have been affecting a patient for a long time. Rest alone after injury usually does not relieve the problems caused by inflammation and spasm; for example, a muscle in spasm may not have adequate blood supply to heal. Protective mechanisms in place in the body following injury alter movement of the whole musculoskeletal system and increase strain on other areas. Physical rehabilitation should commence as soon as is possible for the patient and caregiver. History of Human Physical Therapy International History Physicians such as Hippocrates and, later, Galenus are believed to have been the first practitioners of physical therapy, advocating massage, manual therapy techniques, and hydrotherapy (Physiosite, 2015). In Ancient Greece in around 460 bc, Hector practiced a technique called hydrotherapy (derived from the Greek words for water treatment). In 1894, physiotherapy was recognized in Great Britain as a specialized branch of nursing regulated by the Chartered Society of Physiotherapy. The first emergence of physiotherapy as a specialist discipline was in Sweden in 1913 when Per Henrik Ling founded the Royal Central Institute of Gymnastics (RCIG) for massage, manipulation, and exercise. In the following two decades, formal physiotherapy programs were established in other countries, led by the School of Physiotherapy at the University of Otago in New Zealand in From 1950, chiropractic manipulations were also introduced; this was initially most common in Great Britain. A subspecialty of orthopedics, within physiotherapy, also emerged at about the same time. Developments in the United States In the United States, physical therapists formed their first professional association, called the American Women s Physical Therapeutic Association, in 1921 (Moffat, 2003; APTA, 2015). In 1922, the association changed its name to the American Physiotherapy Association (APA) and in the 1930s, it introduced its first Code of Ethics. At this time men were admitted and the membership grew to just under With the advent of World War II and a nationwide polio epidemic during the 1940s and 1950s, physical therapists were in great demand. The association s membership grew to By the late 1940s, the association had changed its name to the American Physical Therapy Association (APTA). The APTA represents more than members throughout the United States. A national professional organization, APTA s goal is to foster advancements in physical therapy practice, research, and education. Currently 213 institutions offer physical therapy education programs and 309 institutions offer physical therapist assistant education programs in the United States. History of Veterinary Physical Rehabilitation Physical rehabilitation for animals has been practiced since the 1980s. In biomedical research, the use of animal models in treatment protocols is common, and this includes research in the field of physical rehabilitation. From the late 1980s and throughout the 1990s several groups helped to increase interest in canine and equine physical rehabilitation. These groups include the American Veterinary Medical Association (AVMA), the American College of Veterinary Surgeons (ACVS), and the formation of the Animal Physical Therapist Special Interest Group (APT SIG) within the APTA. Success with human patients receiving postoperative physical therapy has galvanized the veterinary community into developing physical rehabilitation techniques that can be implemented for animal patients (McGonagle et al., 2014). In June 1993, the APTA issued a

13 SSecifics About Veterinary Physical Rehabilitation 3 position statement that endorses the position that physical therapists may establish collaborative, collegial relationships with veterinarians for the purposes of providing physical therapy services or consultation (APTA, 1993). In 1996, Guidelines for Alternative and Complementary Veterinary Medicine were adopted by the AVMA House of Delegates (AVMA, 2000) and new guidelines were adopted in 2001 (AVMA, 2001). Training in animal physical rehabilitation was establish by a group at the University of Tennessee (McGonagle et al., 2014). This training and certification course was, and still is, provided for veterinarians, veterinary technicians, physical therapists, and physical therapy assistants. The International Association of Veterinary Rehabilitation and Physical Therapy (www. iavrpt.org) became an official association in July 2008 and is a collaborative association of veterinarians, technicians, physical therapists, and other allied health professionals. Veterinarians interested in rehabilitation in the United States are encouraged to join the American Association of Rehabilitation Veterinarians (AARV), founded in 2007 ( org). Veterinary technicians can become members of the AARV as associate members, as can other allied health professionals. In 2010, the American College of Veterinary Sports Medicine and Rehabilitation was approved by the American Association of Specialty Veterinary Boards (AASVB), in order to establish and maintain credentialing and specialty status for veterinarians who excel in sports medicine and rehabilitation. A veterinarian can become board certified in either canine or equine specialties under this college ( Veterinary technicians can take one of several certification courses in animal rehabilitation, as explained further in Chapter 2. For those technicians that are already certified in physical rehabilitation, a veterinary technician specialty group is under formation. This group is under the umbrella and direction of the National Association of Veterinary Technicians in America (NAVTA), and is called the Academy of Physical Rehabilitation Veterinary Technicians. This specialty certification will allow veterinary technicians and nurses to possess the credential VTS physical rehabilitation. The mission statement of the academy is: We are credentialed rehabilitation veterinary technicians providing assistance in physical rehabilitation, encouraging veterinary technicians to further education, while improving the quality of animals lives. Specifics About Veterinary Physical Rehabilitation The AARV has produced a model set of guiding principles for the ideal practice of veterinary physical rehabilitative medicine (AARV, 2014) These model standards state: Patient care in the rehabilitation facility should be under the authority, supervision or approval of a licensed veterinarian certified in rehabilitation therapy. Initial examination and diagnosis should be determined by a licensed veterinarian with rehabilitation certification. The rehabilitation treatment plan should be formulated and the case managed by a licensed veterinarian with rehabilitation certification, or a combination of this veterinarian in consultation with an appropriately licensed physical therapist certified in animal rehabili tation. No technician/assistant (certified or otherwise) shall manage a rehabilitation patient. There shall be a formal policy in place to monitor and evaluate patient response to care. The practice shall use individualized rehabilitation and therapy plans including fitness plans. For patients with concurrent conditions: Clients shall be advised early in the course of care of the opportunity to request a second opinion or referral to a specialist for treatment of these conditions.

14 4 Introduction for Veterinary Technicians/Nurses The rehabilitation practice shall regularly update the patient s primary care veterinarian as well as any other veterinarian involved with the patient s current care. A summary of the initial rehabilitation evaluation findings should be sent to the referring veterinarian at the earliest opportunity, preferably within 24 hours of the evaluation. The patient shall be discharged back to the care of the primary veterinarian once therapy is complete. When referring a patient for additional workup, appropriate referral communication (such as letter, , phone conversation) shall occur and should be properly documented in the patient s record. Evaluation for pain shall be part of every patient visit. Practice team members shall be trained to recognize pain and work in collaboration with the veterinarian to provide appropriate pain management including physical and pharmaceutical modalities. Since medical and emergent issues may arise during treatment, and pain management monitoring needs to be addressed by a veterinarian, having the rehabilitation veterinarian on site is ideal. A plan must be in place to address emergent care medical issues and pain management in the absence of direct (on site) veterinary supervision. Practice team members should be trained to identify causes of pain, levels of pain, medications and physical methods used to control pain. Pain scores should be documented in the medical record at each visit. Pain management techniques should be used when the presence of pain in a patient is uncertain. Clients should be adequately educated to recognize pain in their pet. Clients should be adequately educated about the possible effects of any dispensed analgesic, including adverse events. Tentative diagnoses and medical plans, or their subsequent revisions shall be communicated to clients at the earliest reasonable opportunity. A rehabilitation veterinarian should have current knowledge of veterinary approved diets, nutraceuticals and supplements as well as knowledge and skills in weight loss and weight management programs. Nutritional assessment and counseling should be part of routine care. Recommended continuing education requirements: Each veterinarian should have a minimum of 15 hours continuing education every 2 years specifically in veterinary rehabilitation topics. Each veterinarian should have a minimum of 20 hours per year of documented continuing education in the field of veterinary medicine. Each veterinary technician should have a minimum of 10 hours of documented continuing education in the field of veterinary rehabilitation every 2 years. Each veterinary technician should have a minimum of 10 hours of documented continuing education in the field of veterinary technology every two years. Each physical therapist should have a minimum of 15 hours of documented continuing education in the field of veterinary rehabilitation every 2 years. Each physical therapist should complete continuing education in their own field as recommended by their governing state board. How do Veterinary Technicians and Nurses fit in? Veterinary technicians must complete either a 2 year (associate s degree) or a 4 year program (bachelor s degree) in the United States. Veterinary nurses are the primary

15 Becoming a CCRA, CCRP, CVMRT, CERA, or CERP 5 para veterinary workers in the United Kingdom and assist vets in their work, and have a scope of autonomous practice within which they can act for the animals they treat. This can include minor surgery. Registered veterinary nurses (RVNs) are bound by a code of professional conduct and are obliged to maintain their professional knowledge and skills through ongoing continuing professional development (RCVS, 2015). In the United States, in approximately 40 states, veterinary technicians are certified, registered, or licensed (Levine et al., 2014). Veterinary technician programs do not include extensive coursework in physical rehabilitation. Most continuing education courses offered at international, national, and local meetings offer physical rehabilitation lectures and hands on laboratories. The AARV provides a full day of lectures at the North American Veterinary Conference, the American College of Veterinary Sports Medicine and Rehabilitation (ACVSMR) offers lectures (canine and equine) at this conference and also a program in conjunction with the ACVS annual symposium. Where Can I Become a Certified Rehabilitation Veterinary Technician? The greatest asset for effective physical rehabilitation is an educated veterinary team (Sprague, 2013). A rehabilitation technician is a certified, licensed or registered veterinary technician who has completed a prescribed curriculum to receive the title of CCRA (Certified Canine Rehabilitation Assistant), CCRP (Certified Canine Rehabilitation Practitioner), or CVMRT (Certified Veterinary Massage and Rehabilitation Therapist). There are currently four certification programs in the United States that offer these titles. Canine Rehabilitation Institute The Canine Rehabilitation Institute (www. caninerehabinstitute.com) offers the CCRA program for veterinary technicians and the Certified Canine Rehabilitation Therapist (CCRT) program for veterinarians and physical therapists at training facilities in Florida and Colorado. NorthEast Seminars NorthEast Seminars ( com) offers the CCRP or Certified Equine Rehabilitation Practitioner (CERP) for veterinarians, physical therapists, and veterinary technicians at the University of Tennessee. Healing Oasis Healing Oasis ( offers the CVMRT program for licensed veterinarians, licensed or certified veterinary technicians, licensed physical therapists, licensed nurses, and or licensed/certified massage therapists at their facility in Wisconsin. Animal Rehabilitation Institute The Animal Rehabilitation Institute offers the Certified Equine Rehabilitation Assistant (CERA) to veterinary technicians and physical therapist assistants. Veterinary continuing education units are currently being applied for through the AVMA ( animalrehabinstitute.com/). What is Involved in Becoming a CCRA, CCRP, CVMRT, CERA, or CERP? Formal educational courses and wet labs are involved for all the certification courses. Each school has its own curriculum. The cost is relatively expensive for a veterinary technician, but this certification may allow the veterinary technician to command a higher salary. You must be a licensed veterinary technician (LVT), certified veterinary technician (CVT), or registered veterinary technician (RVT) in order to attend most of the courses. Veterinary

16 6 Introduction for Veterinary Technicians/Nurses assistants are not accepted in all but the Healing Oasis course. The best way to investigate the programs is to visit the Canine Rehabilitation Institute website ( and look for Certified Canine Rehabilitation Assistant. Practice Regulations for Veterinary Technicians Candidates for certified or registered veterinary technician are tested for competency through an examination which may include oral, written, and practical portions. Every state is different and maintains its own regulations with respect to the practice of veterinary medicine. Practice acts, legislated by states and provinces, often define the responsibilities of the veterinary technician. These responsibilities and duties are dependent in part on the type of employment the individual chooses. Here are links to standards for practice acts provided by NAVTA and the American Association of Veterinary State Boards: state_resou rces1 Act%20Model_FullDocument_ pdf Each person needs to investigate their own state practice act to see what encompasses practicing as a veterinary technician. A rehabilitation veterinary technician should be working under the direct supervision of a credentialed rehabilitation veterinarian who directs therapy. The larger team may be made up of a credentialed physical therapist, the referring veterinarian, a veterinary specialist (surgeon, neurologist, etc.), a veterinary chiropractor, acupuncturist, hospital support staff, the owner, and other trained veterinary professionals. Working in the Physical Rehabilitation Field The duties of the rehabilitation veterinary technician include assisting their supervising veterinarian in evaluations and in performing therapies. Therapies that the technician can provide include application of prescribed physical modalities and therapeutic exercises. Part of patient care is ensuring patient records are up to date and accurate. Proper documentation of treatments should be completed each day. Any member of the rehabilitation team should be able to refer back to the record and understand the needs and past treatments of each patient. Clear client communication and education is also necessary. Chapter 2 Joining a Rehabilitation Team goes into detail about the role of each team member. Pain plays a role in any patient s willingness and motivation. A patient s pain score should be assessed and documented in the medical record during each visit (AARV, 2014). A detailed history should indicate the degree of pain and the disability (Davies, 2014). How does the patient cope with the disability? If changes in a patient s pain level are noted, the supervising veterinarian should be notified. It is very important for the rehabilitation veterinary technician to remain in open communication with their supervisor about anything abnormal or any changes in progress. Much of the certified veterinary rehabilitation technician s day is like that of any other LVT, RVT, or CVT. Animal patients are admitted, housed properly, and kept clean. Often during the day patients are taken outside so they can relieve themselves. Technicians may be required to pull records for the therapist (veterinarian or physical therapist) and to keep patient forms and records sent from the referring veterinarian in order and available. Equipment should be kept clean, orderly and ready for use. Assisting the therapist with their patients and listening to them is all part of the routine. At this point, any veterinary technician could fill this

17 Physical Modalitie 7 position. What sets the veterinary technician apart that is certified in rehabilitation? Therapeutic Exercises Therapeutic exercises are a daily part of the veterinary technician s routine. The owner/ handler must be well educated on the exercise program, especially the home exercise program (HEP). The supervising veterinarian chooses the exercises and the technician carries them out. Exercises target proprioception and balance, specific muscle groups, overall pattern of gait, and overall strength and endurance. Therapeutic exercise equipment may include physioballs, cavaletti rails, balance blocks and discs, weights, tunnels, rocker boards, wobble boards, treadmills, air mattresses, or planks (Coates, 2013). Patient considerations such as motivation, footing, assistive devices, and leash/harness control must be assessed prior to beginning any exercise program, and the therapist/handler body mechanics must be monitored to prevent injury. Exercises are designed to address specific impairments and each is described with a goal, a technique, and a progression (McCauley and Van Dyke, 2013). In order to fully understand the therapies, certification at one of the rehabilitation schools is necessary. Manual Techniques Specialized manual techniques are used in evaluating and treating the patient. One of the techniques the technician is trained in is massage, as described by Coates (2013): Massage Effleurage consists of long slow strokes, generally light to moderate pressure, usually parallel to the direction of the muscle fibers. Petrissage involves short, brisk strokes, moderate to deep pressure, parallel, perpendicular, or diagonally across the direction of the muscle fibers. It may include kneading, wringing, or skin rolling. Tapotement is rhythmic, brisk percussion often administered with the tips of the fingers, primarily used as a stimulating stroke to facilitate a weak muscle and cross friction massage involves applying moderate pressure perpendicularly across the desired tissue. Pressure is maintained in such a way that the finger does not slide across the skin, but rather takes the skin with it. Normal range of motion (ROM) is the full motion that a joint may be moved through. Passive range of motion (PROM) of a joint is performed without muscle contraction within the available ROM, using an external force to move the joint (Millis and Levine, 2014a). Stretching techniques are often performed in conjunction with ROM exercises to improve flexibility of the joints and extensibility of peri articular tissues, muscles, and tendons (Millis and Levine, 2014b). Physical Modalities Physical modalities are often used as part of the patient s treatment plan. They are used as tools to manage pain, weak muscles, inflexibility, limited joint ROM, and to aid in tissue healing (Niebaum, 2013). Physical modalities include the following: Superficial thermal agents hot (thermotherapy) and cold (cryotherapy) Neuromuscular electrical stimulation (NMES) usually used to address muscular weakness Transcutaneous electrical nerve stimulation (TENS) used for pain relief Therapeutic ultrasound a deep heating technique used for rehabilitating musculoskeletal conditions (Levine and Watson, 2014) Low level laser therapy (LLLT) using (not surgical) lasers to accelerate wound healing, promote muscle regeneration, treat acute and chronic pain, chronic and acute edema and neurologic conditions (Millis and Saunders, 2014)

18 8 Introduction for Veterinary Technicians/Nurses Extracorporeal shockwave therapy (ESWT) to increase bone, tendon, and ligament healing, accelerate wound healing, and provide antibacterial properties and pain relief (Niebaum, 2013) Pulsed electromagnetic field therapy (PEMF) to induce biological currents in the tissue. PEMF is approved by the US Food and Drug Administration (FDA) as safe and effective for the treatment of fractures and their sequelae (Rosso et al., 2015). The main therapeutic purpose is for enhancement of bone or tissue healing and pain control (Millis and Levine, 2014a). Additional areas of education include topics such as aquatic therapy, canine orthotics and prosthetics, rehabilitation of the orthopedic and neurologic patient, canine sports medicine, pain management, nutrition and geriatric patients. Conditions that can Benefit from Physical Rehabilitation A range of therapies are used to achieve one or more of the following functional goals: To speed recovery from injury or surgery To increase mobility and flexibility To mprove endurance and agility To decrease pain (Goldberg, 2016) To maintain function and prevent further problems To enhance quality of life. Physical rehabilitation helps an individual that has had an illness or injury to achieve the highest level of function, independence, and quality of life as possible (Sharp, 2008). The success or otherwise of any surgery is as much down to the rehabilitation carried out as to the surgical technique performed. Some of the conditions that benefit from physical rehabilitation are listed in Box 1.1. Rehabilitation offers numerous physiological benefits to patients, including: increased blood flow and lymphatic drainage to the injured area, reduction of pain, swelling, and complications, increased production of collagen, prevention of contractions and adhesions, promotion of normal joint biomechanics (Goldberg, 2016), prevention of other injuries, prevention of or reduction in muscle atrophy, and improved function and quality of movement. Box 1.1 Sample conditions benefiting from physical rehabilitation Orthopedic Postoperative rehabilitation (e.g., stifle or hip surgery, arthrodesis, amputation, ligament/ tendon repair) Acute and chronic soft tissue injuries, involving muscle and fascia, tendon, joint capsule, or ligament (limbs or trunk) Arthritis (long term management) Developmental orthopedic diseases (e.g., hip dysplasia, elbow dysplasia) Trauma and wound care Neurological Postoperative rehabilitation (e.g., decompressive surgery, reconstructive surgery) Central or peripheral nerve injuries Fibrocartilaginous embolism, spinal shock Degenerative nerve disease (e.g., myelopathy, polyneuropathies) Balance/vestibular problems Nervous system trauma General Pain management Athletic/working dogs (performance problems, improving strength and endurance) Obesity Depression Senior care Source: Adapted from Sharp (2008).

19 References 9 Conclusion A rehabilitation veterinary technician s job is complex and fulfilling. There are advancements in veterinary medicine daily, and animal physical rehabilitation is on the cutting edge. Specialized rehabilitation equipment is helpful, but a lot can be achieved without it. Physical rehabilitation is rewarding, even with minimal equipment; all you need is a rehabilitation team. References AARV (American Association of Rehabilitation Veterinarians) (2014) Model Standards for Veterinary Physical Rehabilitation Practice. Updated February 2014; originally published February 7, standards.lasso (accessed April 25, 2015). AARV (2015) What is Rehabilitation? rehabvets.org/what is rehab.lasso (accessed April 25, 2015). APTA (American Physical Therapy Association) (1993) Position on physical therapists in collaborative relationships with veterinarians. American Physical Therapy Association House of Delegates (Program 32). uploadedfiles/aptaorg/about_us/policies/ HOD/Practice/Veterinarians.pdf (accessed June 2017). APTA (2015) APTA History. org/history/ (accessed April 22, 2015). AVMA (American Veterinary Medical Association) (2000) Guidelines for alternative and complementary veterinary medicine. In AVMA Directory. American Veterinary Medical Association, Schaumburg, IL. AVMA (2001) Guidelines for complementary and alternative veterinary medicine. In AVMA Policy Statements and Guidelines. American Veterinary Medical Association, Schaumberg, IL. Coates J (2013) Manual therapy. In Canine Sports Medicine and Rehabilitation (eds. MC Zink and JB Van Dyke). John Wiley & Sons, Inc., Ames, IA, p Davies L (2014) Canine rehabilitation. In Pain Management in Veterinary Practice (eds. CM Egger, L Love, and T Doherty). John Wiley & Sons, Inc., Ames, IA, p Goldberg ME (2016) Pain management in physical rehabilitation. Vet Nurse 7(1): Levine D and Adamson CP (2004) Conceptual overview of physical therapy, veterinary medicine, and canine physical rehabilitation. In Canine Rehabilitation and Physical Therapy (eds. DL Millis, D Levine, and RA Taylor). Saunders/Elsevier, St. Louis, MO, p. 18. Levine D and Watson T (2014) Therapeutic ultrasound. In Canine Rehabilitation and Physical Therapy, 2nd edn (eds. DL Millis and D Levine). Elsevier, Philadelphia, PA, pp Levine D, Adamson CP, and Bergh A (2014) Conceptual overview of physical therapy, veterinary medicine, and canine physical rehabilitation. In Canine Rehabilitation and Physical Therapy, 2nd edn (eds. DL Millis and D Levine). Elsevier, Philadelphia, PA, p. 18. McCauley L and Van Dyke JB (2013) Therapeutic exercise. In Canine Sports Medicine and Rehabilitation (eds. MC Zink and JB Van Dyke). John Wiley & Sons, Inc., Ames, IA, pp McGonagle L, Blythe L, and Levine D (2014) History of canine physical rehabilitation. In Canine Rehabilitation and Physical Therapy, 2nd edn (eds. DL Millis and D Levine). Elsevier, Philadelphia, PA, pp Millis D and Levine D (2014a) Other modalities in veterinary rehabilitation. In Canine Rehabilitation and Physical Therapy, 2nd edn (eds. DL Millis and D Levine). Elsevier, Philadelphia, PA, pp Millis DL and Levine D (2014b) Range of motion and stretching exercises. In Canine Rehabilitation and Physical Therapy, 2nd edn (eds. DL Millis and D Levine). Elsevier, Philadelphia, PA, pp

20 10 Introduction for Veterinary Technicians/Nurses Millis DL and Saunders DG (2014) Laser therapy in canine rehabilitation. In Canine Rehabilitation and Physical Therapy, 2nd edn (eds. DL Millis and D Levine). Elsevier, Philadelphia, PA, pp Moffat M (2003) The history of physical therapy practice in the United States. J Phys Ther Educ 17:5 25. NAVTA (National Association of Veterinary Technicians in America) (1987) Veterinary Technician Code of Ethics. navta.net/about navta/about (accessed October 9, 2014). Niebaum K (2013) Rehabilitation physical modalities. In Canine Sports Medicine and Rehabilitation (eds. MC Zink and JB Van Dyke). John Wiley & Sons, Inc., Ames, IA, pp Physiosite (2015) Physiotherapy History and Applications. (accessed April 25, 2015). RCVS (Royal College of Veterinary Surgeons) (2015) Veterinary Qualifications: Registered Veterinary Nurse: RVN. find a vet/veterinary qualifications/ (accessed April 21, 2015). Rosso F, Bonasia DE, Marmotti A, et al. (2015) Mechanical stimulation (pulsed electromagnetic fields PEMF and extracorporeal shockwave therapy ESWT ) and tendon regeneration: a possible alternative. Front Aging Neurosci 7:211. Sharp B (2008) Physiotherapy in small animal practice. In Practice 30: Sprague S (2013) Introduction to canine rehabilitation. In Canine Sports Medicine and Rehabilitation (eds. MC Zink and JB Van Dyke). John Wiley & Sons, Inc., Ames, IA, p. 83.

21 11 2 Joining a Rehabilitation Team Julia E. Tomlinson 1,2 1 American College of Veterinary Sports Medicine and Rehabilitation, Fort Collins, CO, USA 2 Twin Cities Rehabilitation & Sports Medicine Clinic, Burnsville, MN, USA CHAPTER MENU Introduction, 11 Becoming a Rehabilitation Technician (Nurse), 13 The Rehabilitation Patient, 14 Your Team Role as Rehabilitation Veterinary Technician, 15 Working Under Supervision, 20 Future Directions for the Rehabilitation Technician, 22 Conclusions, 24 References, 25 Introduction People who Work in a Veterinary Rehabilitation Facility A veterinary rehabilitation facility, like any veterinary clinic or hospital, relies on a team of people working together with a common goal. The common goal in a veterinary rehabilitation facility is to improve the quality of life of patients by improving the ability of the animal (and owner) to perform the activities of daily living necessary for the animal s life to be fulfilling. Activities of daily living are daily self care activities in the patient s home. A useful approach in explaining who works in a veterinary rehabilitation facility is to look at it from the point of view of the patient and caregiver (client) entering the facility for the first time. The patient and caregiver will be greeted and welcomed by a receptionist, technician, or manager. The patient and caregiver will then either be directed to take a seat in the waiting room or be guided to an examination room where intake paperwork (and treats) will be handed out. The receptionist s responsibilities are answering the phone, scheduling, admitting, and discharging patients and facilitating the flow of traffic in the building. They may also explain treatment plans and estimates. This person should have a good knowledge of the process of veterinary rehabilitation and the flow of the facility. In our clinic, Twin Cities Animal Rehabilitation and Sports Medicine ( we do not have a conventional receptionist; instead our rehabilitation veterinary technicians and Physical Rehabilitation for Veterinary Technicians and Nurses, First Edition. Edited by Mary Ellen Goldberg and Julia E. Tomlinson John Wiley & Sons, Inc. Published 2018 by John Wiley & Sons, Inc.

22 12 Joining a Rehabilitation Team office manager (also a veterinary assistant) take turns acting as receptionist. This way, each time a current or potential client calls, they are able to speak to someone who is familiar with all aspects of the clinic and can schedule our complicated array of therapies with the appropriate person at the appropriate time. For most patients, the rehabilitation technician will be the first to enter the examination room and will put the patient and client/ caregiver at ease. History taking may be performed by the technician or the rehabilitation veterinarian. Once a complete and detailed history has been taken, the physical and observational examination begins. The rehabilitation veterinarian (along with any other professionals) will make functional and physical diagnoses; using this information they will develop a treatment plan. This plan will include at home and in clinic therapy. The rehabilitation technician will take part in explaining the home and in clinic therapy plan to the client/caregiver in an easy to understand way. In clinic therapies will be performed by a combination of the rehabilitation veterinarian, rehabilitation veterinary technician, physical therapist, and other professionals, such as a veterinary acupuncturist, animal chiropractor, or massage therapist. The person performing the therapy depends on the therapy recommended and on that person s skill set. Many rehabilitation veterinarians have additional training in manual therapies (including manipulations) and in acupuncture. Both physical therapists and chiropractors are trained manual therapists and in order to work in the veterinary world will need to have had additional training and certification in working with animal patients. Team Members The Rehabilitation Veterinarian The rehabilitation trained veterinarian will examine the patient and assess pain level, injured tissues, concurrent disease, and functional limitations. If further diagnostics are needed, they will be performed in order for an exact diagnosis to be made. The rehabilitation veterinarian will develop a treatment plan including at home and in clinic therapy, medications, and recommended nursing care. Other professionals, if present, will contribute to this plan. The rehabilitation veterinarian may be a Diplomate of the American College of Veterinary Sports Medicine and Rehabilitation or be certified in rehabilitation. The Rehabilitation Veterinary Technician The rehabilitation technician will assist with the examination. The technician will assist in handling the patient, and with taking and recording measurements and observations, such as vital signs and pain scoring. The rehabilitation technician will take part in educating the client and explaining the home care and in clinic therapy plan. The rehabilitation technician will also take part in inclinic therapies under the supervision of the rehabilitation veterinarian. The rehabilitation technician should have received specific training in veterinary rehabilitation. The Physical Therapist A physical therapist, trained in animal rehabilitation, can evaluate the animal patient with the rehabilitation veterinarian. A specific diagnosis needs to be made by a veterinarian. Together with the rehabilitation veterinarian, the physical therapist will develop and institute the treatment plan. Physical therapists who work in animal rehabilitation should be certified in veterinary rehabilitation. The Physical Therapist Assistant The physical therapist assistant works under the supervision and direction of the physical therapist and does not evaluate, but is able to perform many therapeutic treatments. Physical therapist assistants who work in animal rehabilitation should be trained and certified in animal rehabilitation.

23 Becoming arehabilitation Technician (Nurse 13 Adjunct Team Members Other team members can include veterinarians who are trained in acupuncture or spinal manipulative therapy (veterinary term for chiropractic) and other veterinarians including specialists (surgeon, oncologist, neurologist, primary care veterinarian and pain specialists). Chiropractors who have received additional training and certification in animal chiropractic along with massage therapists may be involved in care of the rehabilitation patient. Becoming a Rehabilitation Technician (Nurse) A rehabilitation veterinary technician or nurse is a skilled individual who has devoted time, study, and energy into training in the art and science of veterinary rehabilitation. A rehabilitation technician or nurse will be instrumental in the execution of the rehabilitation therapy plan and will often be the first line in noting a change in patient status and advocating for them. Before becoming a rehabilitation veterinary technician an individual will qualify as a veterinary technician or nurse. According to the National Association of Veterinary Technicians in America (NAVTA): veterinary technicians and technologists are educated to be the veterinarian s nurse, laboratory technician, radiography technician, anesthetist, surgical nurse and client/caregiver educator. A veterinary technician is a graduate from a two year, American Veterinary Medical Association (AVMA) accredited program from a community college, college or university. A veterinary technologist has graduated from an AVMA accredited bachelor degree program. Almost every state requires a veterinary technician/technologist to take and pass a credentialing exam. More information is available on the website of the NAVTA ( default.asp?). This training includes education in veterinary anatomy and physiology, pathology, pharmacology, and disease processes. All of this information is essential for someone working in the field of veterinary rehabilitation. Becoming a veterinary nurse in the United Kingdom involves either taking vocational training or a degree course. More resources and information can be found on the website of the Royal College of Veterinary Surgeons (RCVS) at ( and the website of the British Veterinary Nurses Association ( Each country will have its own regulating body, and contacting the main veterinarianregulating body of your country will be the best initial approach to finding out more. Training in veterinary rehabilitation is available at several educational facilities in the United States (Northeast Seminars partnering with the University of Tennessee, Canine Rehabilitation Institute, Equine Rehabilitation Institute, Healing Oasis Education Center). For more information, see Chapter 1. Healing Oasis Education Center and Canine Rehabilitation Institute also run courses in other countries (e.g., Canada, Switzerland, UK, Australia, and Brazil). These courses average 121 hours of education in the format of didactic (lecture) teaching in person and online along with interactive, practical training. This training is followed by a certification examination. It is important to note that these certification courses are self regulating and may differ in content. There is no overseeing body ensuring that information is correct and applicable. Some courses have sought approval from state educational boards (Healing Oasis, for example). After certification, the technician/ nurse candidate gains a certificate in canine rehabilitation (CCRA (Certified Canine Rehabilitation Assistant), CCRP (Certified Canine Rehabilitation Practitioner), or CVMRT (Certified Veterinary Massage and Rehabilitation Therapist)). These courses are

24 14 Joining a Rehabilitation Team available to veterinarians, veterinary technicians, physical therapists, physical therapy assistants, and, in some cases, chiropractors, massage therapists, and veterinary assistants. The certification gained from these courses should always be interpreted in the light of the individual s other qualifications and degrees and does not provide a blanket qualification to practice rehabilitation medicine, or to make a diagnosis and to prescribe therapy. Completion of the certification process and emerging as a certified rehabilitation technician is only the beginning of the journey into this rewarding and fulfilling field in veterinary medicine. The next steps are onthe job training and continuing education, just as a veterinarian always continues their education and learning. Continuing education lectures, laboratories, and seminars in this subject are currently available at many major veterinary conferences. There are also stand alone meetings entirely devoted to rehabilitation, such as the International Association of Veterinary Rehabilitation and Physical Therapy meeting ( which occurs every 2 years and alternates between European and American locations, and the Symposium for Therapeutic Advances in Animal Rehabilitation (STAAR) ( in New Jersey annually. The Rehabilitation Patient Surgical Patients Surgical patients often make up a large proportion of cases in an animal rehabilitation facility. Many rehabilitation facilities are housed in, or adjacent to veterinary surgical facilities. The surgical patient may be seen by the rehabilitation technician/nurse and the supervising rehabilitation veterinarian both before and after surgery. A patient may need to lose weight before undergoing anesthesia or the surgeon may have advised some pre surgical strengthening. Most surgical patients that are referred for rehabilitation will have already had orthopedic surgery, or surgery aimed to improve neurologic dysfunction. The aim of rehabilitation therapy for these patients is to assist in recovery of strength and function; function includes flexibility and coordination. The specialist surgeon will give input to the rehabilitation practitioner about restrictions in activity relative to stability of the surgical repair/procedure. This input is from a unique perspective as only the surgeon has seen the full extent of tissue damage and the relative success (or struggle) in repairing and minimizing the effects of that damage. The surgeon will be principally concerned about healing of the surgical site and may want to be more conservative than the rehabilitation team. Understanding the surgeon s point of view and acting with collegiate respect is important, however the surgeon may need to be enlightened about the process of rehabilitation and the appropriate qualifications of the people he or she is working with pertinent to case management. Restricting activity and motion of the affected area unduly can transform the detrimental effects of immobilization from a temporary to a permanent one. In human medicine, mobilization of a patient after repair of a complex spinal fracture begins immediately post operatively (J Yeater, personal communication, 2015). A rehabilitation veterinarian should be the person to govern communications with the surgeon. The Injured Non surgical Patient These are patients with a physical injury or disease affecting mobility and comfort for which surgery is not indicated, or in some cases not possible for reasons such as the risks of anesthesia. Many soft tissue injuries are treated this way. Having a specific diagnosis of tissue pathology as well as a diagnosis of functional limitations is of paramount importance. An exact diagnosis still needs to be reached in order to formulate an appropriate rehabilitation plan. Lame patients referred for strengthening should

25 Your Team Role as Technician 15 be carefully evaluated and diagnosed by the veterinarian before the onset of rehabilitation therapy; for example, exercising a patient with a severely damaged tendon can cause further pathology. The aim of rehabilitation therapy for the injured patient is to manage pain and restore maximal function. Patients with Chronic Degenerative Disease Chronic degenerative diseases (e.g., osteoarthritis, immune mediated polyarthritis, degenerative myelopathy, spinal stenosis, obesity) all affect mobility and strength. The aim of rehabilitation therapy for these patients is to improve function in the light of their disability, to manage pain and to improve quality of life. Even an unstable neurologic patient with permanent nerve damage can improve gait with improved strength, because they can overcome the forces of motion while ataxic, and improve forward momentum and stabilization if their muscles are working well. Balance and proprioceptive exercises can result in a relative improvement in overall stability. Geriatric Patients As individuals age, they lose muscle (this muscle loss is termed sarcopenia) and fine motor control/balance along with strength. The relatively immobile patient is also prone to obesity. Aging is not a disease process, but the incidence of systemic disease does increase with age. The aim of rehabilitation therapy for these patients is to improve their quality of life through pain management, improvements in mobility, and regaining the ability to perform the activities of daily living even if this requires the use of assistive devices (see Chapter 10). Concurrent morbidity (e.g., bladder infections from incomplete emptying in the weak patient) must be taken into account and, of all the rehabilitation patient populations, this aged one needs the most frequent veterinary intervention. The Canine Athlete/Working Dog Working with canine athletes is an extremely rewarding process. Trainers/caregivers are motivated and generally knowledgeable. These patients cannot self advocate and yet they have the drive of a human professional athlete; injuries are common. The aim of rehabilitation therapy for these patients is return to sport or work. A survey of agility owners found the injury rate of agility dogs to be 32% at the time of survey (Cullen et al., 2013). Injury rates in young human athletes vary from 12% to 28% depending on sport. This is of great concern to doctors because conditioned adult athletes have only a 2 3% injury rate (AOSSM, 2009; Ganse et al., 2014). Part of the problem for young human athletes is their open growth plates when training; part is thought to be due to inadequate conditioning and relative overload. Conditioning plans have the potential to reduce injury rates in sporting dogs along with maintenance therapies (usually manual therapies and acupuncture, possibly therapeutic modalities). The goal of conditioning is to optimize the performance of the athlete and minimize the risk of injury and illness. Training adaptations are specific to the nature of the exercise (e.g., muscle contraction type and mechanics) and so conditioning should be appropriate for the demands of the sport. For example, long periods of trotting or walking exercise are an inappropriate conditioning plan for a sprinting athlete. Your Team Role as Rehabilitation Veterinary Technician Being a Patient Advocate As a rehabilitation veterinary technician/ nurse, you will be one of the team members who interacts most with both patient and client/caregiver. As you provide veterinarian prescribed therapies, the time that you spend with the patient and client/caregiver

26 16 Joining a Rehabilitation Team will give you a unique insight into the personalities of both, and this will help you to quickly recognize changes in patient status. When you encounter a patient for the first time, there will need to be an immediate assessment of patient demeanor (all people experienced with working on animals tend to do this automatically) and an understanding of how this particular patient may respond to novel situations and touch. Clients may not be immediately forthcoming or even honest with themselves about how their loved one reacts to unfamiliar situations. Taking time to put the patient at ease, no matter how long that takes, is crucial to enable a full examination and functional assessment. The rehabilitation examination is extensive and relies on a lot of touch, including physically moving the patient around. If pain is an issue, the patient may react in an aggressive manner. It is therefore paramount that proper pain management be included in the final analysis. A relatively relaxed patient is easier to examine from the point of view of compliance but also from the point of view of identifying areas of discomfort. Understanding animal behaviors, including signs of stress and fear, and having fundamental training skills will go a long way towards enabling an easy examination and a low stress process. Animal behavior is a branch of veterinary medicine that extends into everything we do. If we can put our patients at ease, future therapy visits will go well. History taking may be performed by the technician or the rehabilitation veterinarian. History taking is often a lengthy process and includes questioning the client about the exact home environment (e.g., flooring and stairs in the home, pain scoring using home behaviors, patient activity level, and number of walks each day), timeline of the problem, any current or previous treatments and medications, other concurrent disease and activity level before the issue (owner expectations of return to normalcy). The examination is a full physical and functional assessment. Once a complete and detailed history has been taken, the physical and observational examination begins. The rehabilitation examination looks for areas of dysfunction and pain. The examination includes subjective and objective observations, Examples of subjective observations include conformation and posture, stance and sit position, transitions between postures, ability to hold posture, and response to palpation (both static palpation and palpation during movement of a joint, stretch of a muscle. etc.). Objective observations are those that can be measured, for example measurement of thigh girth with a spring weighted tape measure, using a stance analyzer to assess the weight put through each paw, and gait analysis. As rehabilitation technician, you will assist the rehabilitation veterinarian and any adjunct professionals with their examination. The rehabilitation technician assists in handling the patient, applying restraint, if needed, using a minimal restraint approach. The technician may also be responsible for taking and recording measurements and observations, pain scoring the patient, and charting. The rehabilitation examination takes longer than a routine clinical examination and keeping the patient and client relaxed and focused can be a challenge. The rehabilitation veterinarian will make a physical diagnosis and a functional assessment. Using this information, they will develop a treatment plan. This plan will include at home and in clinic therapy. The rehabilitation technician will take part in explaining the home and in clinic therapy plan to the client/caregiver in an easy tounderstand way. Communication skills and empathy are essential parts of being a rehabilitation veterinary technician, just as they are for a veterinary technician or nurse working in general practice. The technician is often the translator of words from medical terminology to accessible terms, and can repeat an explanation of the diagnosis in a different way. In many cases, the visit to the rehabilitation veterinarian is the last in a long list of visits to several veterinarians, and so clients may be frustrated with the long process and need time and a sympathetic ear to

27 Your Team Role as Technician 17 vent these frustrations. Part of the skill of communication is the ability to listen without interrupting and to help the client feel heard before moving on with a full explanation of the treatment plan which engages the client as part of the therapy team. The rehabilitation technician will go over the recommended plan with the client/caregiver using a step by step approach. This will include a financial estimate for the inclinic plan, explaining the in clinic therapy plan along with prescribed medications and supplements, and then covering the home therapy plan. The client/caregiver should gain a thorough understanding of the initial plan, therapeutic goals, and the potential for changes in the plan. They should be educated about the time consuming nature of therapy, along with having an understanding of reasonable benchmarks for improvement (expectations) and how long it can take for even small improvements to occur. Any questions that arise from the client/ caregiver can be addressed directly by you or conveyed to the rehabilitation veterinarian. Finally, mediating the checkout at reception by scheduling a set of therapy visits before the client leaves can help to improve compliance. As one of the main people communicating with the client, the rehabilitation technician should make sure that the client knows how to contact the clinic with any follow up questions prior to next visit the large amount of information generated from the first visit often takes time to digest and questions can come up later. Talking casually with client/caregivers during therapy sessions and asking gentle questions about home progress can often reveal potential pitfalls in the home care plan and other red flags: Fluffy doesn t chase squirrels in the back yard so I decided he needed some off leash time. You are also uniquely situated to address concerns and to notice early and subtle changes in patient status: Sam is not getting any better, I am worried that therapy isn t working and We had a great Christmas thanks for asking, apart from Sam did get on the kitchen counter and stole a ham; he hasn t done that in years! Information revealed during conversations can be used to gently counsel and guide the client/caregiver regarding small positive or negative changes. Any issues of potential concern can then be discussed with the client/caregiver and with your supervising veterinarian so that you can implement any change in therapy plan. Plan changes should then be explained to the client/caregiver. The special relationship that develops during therapy between you and a client/caregiver means that you are uniquely situated as an ally and confidant, more so than the veterinarian or other professional. You may be the only person able to gently point out to a client/caregiver that they are being noncompliant, without seeming judgmental or negative. Sometimes the technicians that I work with will use an indirect approach and tell the dog that they cannot go off leash yet, and even though they feel better, it does not mean that they are fully healed. The rehabilitation veterinary technician also has the opportunity to gently remind the supervising veterinarian of issues. For example, the enthusiastic home plan with 15 separate exercises devised by the veterinarian may be overwhelming an otherwise compliant client/caregiver. Perhaps the client/caregiver has downplayed a physical issue that they themselves have, which restricts their ability to implement the home plan. It may be that the owner is at risk of getting bitten and did not want to admit that to the rehabilitation veterinarian. Observing a patient for a relatively long period during therapeutic visits may also highlight an issue that was not noted during the initial examination. The rehabilitation technician can become a skilled observer of gait and function and use this information to alert the veterinarian of the need for reassessment. Many patients in rehabilitation are at risk of, or are already suffering from concurrent disease, this can be as simple as a mild gastrointestinal upset, a medication reaction/ interaction, or it may be a more complex

28 18 Joining a Rehabilitation Team systemic issue (diabetes, chronic kidney disease), or even an acute crisis such as a gastrointestinal bleed. As a veterinary technician, your skill set extends beyond rehabilitation, and using your other skills and knowledge of medicine will be needed daily. You will need to be able differentiate important issues, which require a halt in therapy and immediate veterinary attention, from mild issues that can be monitored. Working with clients over the phone is another important part of the rehabilitation technician s job. Questions about therapy, the rehabilitation process and other medical questions can often be answered immediately, the rehabilitation veterinarian is involved only an as needed basis. This gatekeeping and educating job is very much a part of a rehabilitation technician s role and should not be undervalued. Providing the Prescribed Therapies Learning how to provide therapy takes time and teaching by an experienced rehabilitation team. Introduction to modalities and therapeutic exercises is provided at the rehabilitation courses. Most of your skill, however, will be gained on the job under supervision. Knowing when to apply therapy appropriate for the diagnosis is the job of the supervising rehabilitation veterinarian; a physical therapist trained in animal rehabilitation may also provide a therapy plan once a veterinary diagnosis has been made. Complex manual therapies are not provided by the veterinary technician and require additional training before they can be provided by a veterinarian. Physical therapists learn manual therapy techniques during their years in school, but still need additional training in specifics of animal anatomy and biomechanics before applying their skills (quadrupeds are very different to bipeds, horses are very different to dogs). Your supervisor will advise and teach you appropriate light manual therapies such as massage and stretches, you can also gain additional training such as massage. Your knowledge of veterinary anatomy and physiology will help you to understand and apply therapy to the appropriate site, for example knowing the specific origin and insertion of a muscle and the direction of the fibers can help you to apply therapeutic ultrasound and follow it with cross fiber massage. During therapy you will note any response from the patient. The subtlest signs of discomfort can be identified by a skilled veterinary technician/nurse. Signs of discomfort need to be differentiated from signs of general stress or restlessness. Halting the therapy for a moment and noting whether the patient then relaxes while still being restrained is a simple method of differentiating discomfort due to therapy from discomfort due to restraint so that you can alert your veterinarian when appropriate for a change in plan. Bribery goes a long way during treatment sessions, high value treats (and a variety of treats, from immediate reward to those needing some work to eat) help to ease patient tension and improve compliance. In our clinic (Twin Cities Animal Rehabilitation and Sports Medicine), we often ask that owners refrain from buying the same treats that we use in clinic. That way the patients happily visit for special treat time. Most of our patients come into a therapy room and point their nose straight at the treat bucket. Assessing pain level is a part of each therapy visit. Question the owners about home behaviors and note in clinic behaviors and response to palpation. For example, when we provide laser therapy, we can palpate the treatment area before and after therapy and note whether we get some immediate pain relief. Client/Caregiver Education Education of the client extends from helping them to gain an understanding of the disease process or injury to helping them to be part of the rehabilitation team for their pet. The rehabilitation technician will need to teach the owner the therapeutic exercises that will be performed at home. Teaching is

29 Your Team Role as Technician 19 Figure 2.1 Your team will have developed strategies for teaching, including handouts with pictures, posters, models, and step by step instructions. Explain and demonstrate the exercise, then it is time for the client to practice. a skilled job, and your team will have developed strategies, including handouts with pictures, online video demonstrations, and step by step instructions to aid you (Figure 2.1). First demonstrating the exercise slowly to the owner, then watching them perform the exercise and giving gentle hints and tips is advised. Every person learns in a different way and so providing a demonstration, hands on practice, and reminders to be used later is a good way of ensuring that everyone is on the same page. A review of home exercises should occur at regular intervals (for example weekly) during inclinic therapy visits and, as the patient progresses, new exercises will need to be demonstrated. When teaching a home exercise, remember to take into account the fact that there may be multiple members of the household responsible for therapy and that not all clients will be skilled at teaching other household members. Clients also need to be taught to watch for postural decompensations and cheating during specific exercises. Nursing Care Part of nursing care is patient advocacy as described earlier in this chapter. Physically caring for a patient in clinic involves, for example, addressing discomfort, identifying areas at risk for pressure (bed) sores, and making sure elimination is occurring adequately at home and that the patient is clean. Having the necessary skills to express a bladder, pass a urinary catheter, and evacuate a rectum manually or via enema is part of a veterinary technician s training. Pain management involves the use of pharmaceuticals, manual therapies, and modalities and the protocol for each patient may need to be adjusted at each visit. Grooming to remove excess hair from paws to improve traction, nail trimming, and removing excess hair from the perineum is important for patients with disabilities. Counseling owners about the home environment, home modifications, assistive devices, and home nursing care is time consuming and adequate time needs to be devoted to this. For more on nursing the disabled patient, see Chapters

30 20 Joining a Rehabilitation Team Working Under Supervision Working with a Diagnosis and Prescribed Therapies A veterinary technician is legally obligated to work in veterinary medicine under the supervision of a veterinarian. The veterinarian is responsible for the diagnosis and for the therapeutic plan. Adjunct professionals may contribute to this plan; however, they are not suitable supervisors for veterinary technicians. Both the veterinarian and veterinary technician have skills that complement each other and so make up a team. It is sometimes the belief of general practitioners that veterinary rehabilitation is solely the practice of therapeutic exercise and that any person can quickly become skilled in veterinary rehabilitation ( there is not much to it ). This is very far from the truth. The rehabilitation examination should be one of the most extensive examinations that a veterinary patient undergoes. Patients arriving with an existing diagnosis are not an exception to this, just as a neurologic examination is different to an orthopedic examination despite some overlap, so a rehabilitation examination is very different. Patients undergo a thorough assessment of function, including pain level, muscle tone, strength, and mobility with objective measurements. The whole body is examined, not just the injured area. Compensatory issues are identified and a treatment plan covers all issues, including any systemic disease, endocrine issues, nutritional status, body condition, and body composition. Any rehabilitation patient who is not examined this way is done a disservice. Therapeutic approach changes frequently as patient status changes, if patient compliance is a challenge, or if inadequate progress is being made. The rehabilitation veterinarian and technician will be in constant communication. Daily medical rounds are recommended. Rehabilitation technicians will apply and assist with therapies and are therefore closely monitoring a patient just as a technician would monitor a hospitalized patient; parameters are set for when to change the plan and when it is necessary to consult your supervisor (Figure 2.2). The same protocol of communication with the veterinarian applies to all aspects of veterinary medicine. Figure 2.2 Daily medical rounds are recommended. Parameters are set and recorded for the therapy, when to change the plan, and when it is necessary to consult your supervisor.